States hit hardest by the ravages of tobacco are often the least aggressive at hitting back, a USA TODAY analysis found. So a deadly culture of smoking lingers, which officials say is fueled relentlessly by tobacco companies targeting minorities and the poor.

According to USA TODAY's analysis:

• Big tobacco-growing states such as Kentucky, Tennessee and Georgia have the poorest and sickest residents, yet spend less than 20% of the federal government’s recommended minimum for tobacco education and enforcement.

• States with the most smokers weaken their own tobacco control efforts with cigarette taxes of 60 cents or less, compared with $3.75 in Rhode Island and $4.35 in New York.

• Hard-hit states also do the least to restrict smoking in places such as restaurants and workplaces and impose penalties of $100 or less on businesses selling tobacco to children, compared with $10,000 in the most aggressive states.

USA TODAY analyzed government smoking data to create two scores for states: an “impact score” that combines adult and youth smoking rates and public perception about the risks of smoking; and an “aggressiveness score” combining cigarette taxes, smoking bans, state spending compared with the minimum recommended by federal health officials, advertising restrictions and penalties on sales to young people.

States scoring high on aggressiveness and low on tobacco impact include Hawaii, New York and Utah. But Kentucky, Tennessee, Missouri, West Virginia and Mississippi rank among the worst on both counts — left behind as cigarette smoking nationally hits a historic low.

In places like Kentucky, “smoking is part of life,” says oncologist Goetz Kloecker, a lung cancer specialist with University of Louisville Physicians. “I have patients who started puffing at 8, 9, and 10 years old.”

Longtime smokers pay a heavy price. The 2014 U.S. Surgeon General’s 50th anniversary report on smoking and health concludes that smoking not only causes such well-known tobacco-linked illnesses as lung cancer and cardiovascular disease, but also diabetes, rheumatoid arthritis, ectopic pregnancy and colorectal and liver cancers. Each year, the habit kills 480,000 Americans and is responsible for $300 billion in health care costs and lost productivity.

Brian King, a deputy director in the U.S. Centers for Disease Control and Prevention’s Office of Smoking and Health, says the best ways to reduce smoking are to regulate it, raise cigarette taxes, have a hard-hitting anti-tobacco campaign and put enough money behind tobacco control. But anti-smoking forces in government are “outgunned,” King says, since the tobacco industry spends about $1 million an hour advertising tobacco.

Making matters worse, states have been using money from a huge legal settlement with tobacco companies “to pave roads and fill in potholes” rather than pay for smoking-related health costs, says La Tanisha Wright, who worked as a trade marketing manager for Brown & Williamson Tobacco in the early 2000s. “The money is not hitting the low-income communities that have been hit with the most disease.”

Wright, who now runs the anti-tobacco group Follow the Signs, says she used to visit stores with $500 stuffed in her pockets and shoes to hand out to promote her brands in minority communities. She says tobacco companies still heavily promote menthol cigarettes in these places because they know they are more addictive and favored by African Americans.

Poor people, young people and those without a college education are most likely to fall prey to tobacco marketing, says physician Rahul Gupta, commissioner of West Virginia’s Bureau of Public Health. “They are the most vulnerable among us and these (tobacco) companies know that.”

But tobacco company officials deny they target young people or non-smokers. David Howard, spokesman for Reynolds American Services, says “our marketing and promotional efforts are national in scope and are focused on one audience, adult tobacco consumers — all adult tobacco consumers,” and communicating about brand choices with those who “have made the informed decision to use tobacco” is crucial to competing in the marketplace.

"Time warp" in struggling states

Family Health Centers smoking cessation facilitator Mike Cooper demonstrates how to properly use a nicotine patch. Cooper had two heart surgeries, one due to a heart attack, but continued smoking. However, when his 5-year-old grandson asked him to stop, Cooper enrolled in a Family Health Centers course. "Here I was still doing it after having gone through all of that and even a 5-year-old knew it was bad," Cooper said.(Photo: Alton Strupp, The Courier-Journal)

Marlboro Lights were the brand of choice for Michael Cooper of Louisville, Ky., who picked up his first cigarette at age 12 because it seemed the normal thing to do. “Anywhere you went, you could smoke. And just about anywhere you went, people were," says Cooper, who went on to smoke a pack a day for most of his adult life.

Cooper quit smoking after suffering a heart attack in 2006, only to take it up again four months later.

Cooper’s story is common in Kentucky, which scored worst in the nation for tobacco impact and seventh-worst for aggressiveness in USA TODAY’s analysis. While smoking is banned in workplaces and public places in some cities and counties, there’s still no statewide smoking ban. Cigarette taxes are only 60 cents pack. And the state spends 10.7% of the minimum recommended by the CDC for tobacco control.

Stephanie Mayfield, commissioner of the Kentucky Department for Public Health, says the CDC’s calculations don’t capture all the state’s anti-tobacco spending. She points to a new statewide initiative that aims to reduce smoking 10% by 2019 and an order last year by outgoing Gov. Steve Beshear to make all executive state property smoke-free. “There’s momentum that has been set in place,” Mayfield says, citing slight drops in smoking rates in the last couple of years.

Officials in West Virginia, which ranks second-worst for tobacco impact and 10th worst for aggressiveness, say they’re also striving to do better by developing the state’s first tobacco control plan and focusing especially on young people, who increasingly are reporting they’ve never smoked.

But both states face tight budgets. West Virginia spends about 40% of the CDC’s recommended minimum on tobacco control but has seen steady declines in the amount it gets from the federal government and state legislators. After holding steady at $5.7 million from 2009-2013, funding for tobacco programs dropped to $5.3 million the next year and is now about $4.8 million.

Gupta says his department has to stay “in touch with reality” when it asks for money, recognizing what the governor and legislature are likely to approve. Just keeping the tobacco education budget at the same level, he says, “is itself a challenge.”

La Tanisha Wright is a former trade marketing manager for a tobacco company that was acquired by R.J. Reynolds. She now warns about predatory marketing by "Big Tobacco" and is the founder of the organization Follow the Signs.(Photo: Jayne O'Donnell, USA TODAY)

Only two states — North Dakota and Alaska — meet CDC minimums for tobacco control funding, which vary by state and take into account factors such as the size of a state and smoking prevalence. A 2013 report by a coalition of health groups says states received $391 billion in revenue from the tobacco settlement and tobacco taxes but spent only 2.3% of this on tobacco prevention programs.

Critics say one reason some states aren’t very aggressive is that tobacco is woven tightly into their communities even as the number of tobacco farms continues to shrink. “You can look at a map of tobacco control policies and see that every state that has weaker policies is a tobacco-growing state,” says Yvonne Hunt, who heads the tobacco control research branch of the National Cancer Institute.

Sitting in a cancer education booth at a free health clinic in southwest Virginia this summer, Virginia Commonwealth University School of Pharmacy student Anesa Hughes tried to explain why smoking is so common in her area. It’s “such a cultural thing,” says Hughes, who walked behind a tiller on her family’s tobacco farm starting at age 8. “It’s like we’re in a time warp.”

Signs of change

Anesa Hughes, who is going to graduate school to become a pharmacist, sits at the cancer education displays at a Remote Area Medical free clinic in southwest Virginia. Hughes grew up helping out on her family's tobacco farm starting at age 8, but now tries to educate people in her area about the health risks.(Photo: Jayne O'Donnell, USA TODAY)

But even in tobacco-growing states, experts say making cigarettes more expensive can do a lot to bring down smoking rates. Connecticut, with about 2,000 acres of tobacco known for its use in cigars, still manages to have the second-best impact score in the USA TODAY analysis. Connecticut officials credit the state’s early adoption of indoor smoking prohibitions, a free smoking cessation hotline and a $3.65-a-pack cigarette tax, which will rise to $3.90 next July.

While smoking has gone down among all groups in the state, eliminating disparities has proven challenging, says William Gerrish, a spokesman for the state health department. Connecticut adults with less than a high school education are 3.5 times more likely to smoke than college-educated adults, for example, and more than a quarter of adults in households making less than $25,000 a year smoke cigarettes, compared with about 9% in households earning $75,000 or more.

The only state that scores better than Connecticut on tobacco impact is California. While its cigarette tax is only 87 cents and tobacco control funding has fluctuated in recent years, the state bans tobacco sales in pharmacies and restricts the location of tobacco retailers. Officials also point out they've maintained a 25-year program using a portion of tobacco tax revenue for a hard-hitting media campaign and community efforts to change “social norms” around tobacco use.

The CDC’s King says “social denormalization” is crucial to tobacco control, and also needs to happen in states and communities where smoking is more common and accepted.

“Big Tobacco is still preying on those at highest risk of death and disability due to tobacco,” says Chad Morris, an associate professor of psychiatry at the University of Colorado. About 70% of the most vulnerable people who smoke want to quit, he says, but it’s more difficult for them because they are bombarded by tobacco company messages and are more likely to lack access to smoking cessation — something doctors hope starts to change now that more people are getting regular health care under the Affordable Care Act.

Smoking cessation classes helped Cooper finally stub out his cigarettes in 2011, and he now teaches other smokers how to quit at a local medical clinic. His grandson was his inspiration.

“If he asked for the moon, I’d try to do it. I didn’t want to let him down,” Cooper says. “Now, my health is better. I can breathe easier. All in all, I’m much better off.”

Tobacco's impact, and state aggressiveness against smoking

USA TODAY analyzed government data to create two scores for states on the impact of smoking and on government action to combat smoking.